The combination of receiving applied behavior analysis (ABA) therapy as a child, my previous experience as a preschool teacher, and pursuing my career goal of becoming a child and adolescent psychiatrist has made me aware of the challenges associated with addressing behavioral difficulties in neurodiverse youth. Many of these challenges stem from disruptions in routine and/or unpleasant sensory experiences, among other difficulties unlikely to affect neurotypical individuals.
Reflecting on a personal experience from my days teaching preschool students, I vividly recall an emotional incident during a routine transition from inside to outside time. Despite the seemingly minor change of lining up in reverse alphabetical order, instead of the usual order, one of my students experienced profound distress. This usually happy and energetic boy became inconsolably upset at the change and required extra time to calm down before transitioning. This inflexible response, characterized by distress and resistance to change, is emblematic of the core diagnostic feature of autism spectrum disorder (ASD) involving adherence to restricted and repetitive activities.1 Such disruptions not only impact the individual but also affect their support networks. My firsthand encounters with similar challenges as a teacher and as a medical student have provided valuable insights into the struggles faced by individuals and families dealing with behavioral challenges. In this article, I describe several interventions proven effective at improving emotional outbursts within the context of ASD. In addition, I review how proactive measures aimed at setting clear expectations and offering structured support play a pivotal role in preventing distressing episodes.
It is also important to acknowledge that accessing professional support is a challenge for a significant number of patients with ASD. When discussing the disparities in mental health care access, the role that state and federal governments play in addressing them should be addressed. I am fortunate to work in Arizona, which has state-sponsored programs, such as Child Find and AzEIP, supporting therapies for children from birth to 5 years of age. While every state has Medicaid benefits for those who have intellectual and developmental disabilities, these funds are often insufficient to cover the breadth of resources that may be required. Therein lies the problem for many families, as the mental health care system for people with ASD is fragmented and requires families to navigate multiple agencies and providers, which creates an inefficient and frustrating system even for those who can access resources.
When discussing interventions to support individuals with ASD, it is essential to consider the root cause of problematic behaviors and to address them with a thoughtful and methodical approach appropriate to the severity of the situation. There is a shortage of patient-friendly materials with appropriate health literacy levels regarding how to address irritability or aggression in children with ASD. However, a few algorithms, such as the recent publication in the British Columbia Medical Journal by Dr. Ooi and the team at BC Children’s Hospital, outline common causes and escalating interventions targeted to the specific problem behavior.2 Although there are a few pharmacological interventions effective at treating targeted symptoms, they should be reserved for behaviors refractory to nonpharmacological intervention to minimize medication overuse.
If the child can access behavioral therapy through insurance or programs at their school, it can be highly effective. Specialists trained in ABA will identify triggers behind disruptive or problematic behaviors and create a system to practice the desired alternative to the problematic behavior. ABA has shown positive improvements in most studies in the domains of cognition, development of language, social skills and communication, and adaptive behavior, along with reductions in problem behavior.3 Positive reinforcement through token economies is a component of ABA therapy that, in my experience working with children with ASD, creates a fun and memorable reinforcement strategy to help change behaviors without any punishment or discouragement. Some interventions can be trialed at home with minimal cost to families before considering a potentially costly visit to a professional. For example, families can implement visual aids, such as play timers and daily activity charts with tangible cues, which have proven effective in my experience in helping individuals manage transitions and variations in their routine.
In addition to ABA therapy, individuals with ASD who exhibit hypersensitivity to sensory stimuli may benefit from integrating sensory therapy into their routine. Through redirecting and offsetting the internal tension associated with certain sensory inputs, sensory integration therapy has proven beneficial in enhancing the ability to adapt to changes in their environment.4 In practice this might include incorporating pleasant smells to calm the patient or an object that can be manipulated in their hand to help self-soothe and cope with sensory input.
While the aforementioned interventions have focused on the emotional outburst itself, improving underlying sleep deficits may also improve sensitivity to routine changes. Children with ASD commonly have difficulty falling and staying asleep.5 Behavioral interventions are the first-line intervention, such as implementing strategies to improve sleep hygiene.6 This can be achieved through establishing bedtime routines and avoiding screens before bed. If behavioral interventions alone are insufficient, then administering melatonin has shown good evidence for improving sleep onset in children with ASD.7 Any parent or educator who works with children with ASD will tell you that there is a visible difference in distress tolerance with vs without a good night’s sleep.
Children with ASD also commonly have comorbid anxiety, which only increases with age.8 As such, treating anxiety may help improve underlying tension leading to difficulty with transitions. Cognitive behavioral therapy is the first-line approach with the best evidence.9 If therapy alone does not have the desired effect, then selective serotonin reuptake inhibitors (SSRIs) may be valuable adjuncts.10 SSRIs have the added benefit of assisting with comorbid obsessive-compulsive disorder (OCD) or OCD-related behaviors. Specifically, fluoxetine has been shown to improve repetitive behaviors and inflexibility related to OCD associated with autism.11 Other pharmacological options to consider as part of a multimodal approach include aripiprazole and risperidone, which are FDA-approved for irritability.
While pharmacological interventions are a useful tool, my professional experience underscores the significance of prioritizing behavioral and environmental strategies as the initial approach. By integrating these interventions, we can effectively support individuals with ASD in managing disruptions to their routine and fostering positive outcomes while being sensitive to cost. As a provider, it is important to remember that many patients have had to overcome significant barriers to come to the office setting. Many options discussed herein (see the summary in Table 1) can be attempted at no cost, depending on insurance and state programming. It is our responsibility to educate members of our community about their options, especially considering the long wait times to see child and adolescent psychiatrists.
About the Author
Ben Pope, BS, is a fourth-year medical student at the University of Arizona College of Medicine in Tucson and is interested in pursuing child and adolescent psychiatry as a career.
Correspondence to:
Ben Pope, BS; email: bapope@arizona.edu, 1501 North Campbell Avenue, Tucson, AZ, 85724.
Funding
The author has reported no funding for this work.
Disclosures
The author has no relevant financial disclosures or conflicts of interest.
Author contributions
Writing – original draft: Ben Pope (Lead).